Patient Consent for Care & Treatment

Empowering Healthcare Services · FusionCare

This Consent Form is provided by Empowering Healthcare Services and its affiliated subsidiary, FusionCare. Empowering Healthcare Services is dedicated to providing comprehensive, patient-centered medical care and support services. Together, Empowering Healthcare Services and FusionCare are committed to maintaining high standards of quality care, patient privacy, regulatory compliance, and compassionate healthcare services for all patients served.

Our clinicians use a variety of evidence-based, individualized treatment approaches to meet each patient's unique needs. We believe individuals are experts in their own lives and encourage active participation in the treatment process. Treatment practices, goals, and any limitations of the treatment plan will be discussed openly throughout the therapeutic relationship to support informed decision-making and collaborative care.

This consent is intended to support and protect the health, safety, and overall welfare of our patients. It is our responsibility to ensure appropriate care and treatment are provided when necessary while recognizing and respecting each individual's right to autonomy and control over their own body. By signing this consent, the patient acknowledges and authorizes treatment.

Treatment / Counseling. Services offered to help patients cope with mental health illnesses, not limited to depression, anxiety, dementia, grief, loss, or transitional anxiety.

Teletherapy. Teletherapy is the delivery of psychological treatment and consultation via interactive internet technologies, with the patient and clinician not in the same physical location.

Consent to Record. Sessions are recorded solely for quality control purposes to allow accurate and thorough documentation of patient treatment.

All information provided will be treated as confidential and will not be disclosed without the individual's consent, except where disclosure is required or permitted by law. The service's electronic systems incorporate established network and software security protocols, including encryption, to protect and maintain the integrity of confidential patient information.

I hereby consent and authorize Empowering Healthcare Services and FusionCare to provide medical care and treatment deemed necessary and appropriate for the diagnosis and treatment of my physical and mental health conditions.

Acknowledgements I fully understand and accept the terms above.* I authorize the release of any medical or other information necessary to process insurance claims.* A verbal and/or affirmative expression was hereby received to relate agreement of consent to treat.

Patient

Patient Name *

Signature (type full name) *

Typing your name acts as your electronic signature.

Date *

Authorized Representative (if applicable)

Representative Name

Signature (type full name)

Date

Setup needed: paste your Web3Forms access key into ACCESS_KEY in the <script> block of this file. Until then, “Submit” shows you the captured data instead of sending it.

Your information is transmitted securely. Submitting this form does not create a treatment relationship by itself; our team will confirm next steps.